Transcript Med Home Case Review Week 14_05152015

MEDICAL HOME
CASE REPORT
Anthony Bailes, MAcOM, L.Ac.
DAOM Candidate 2015
Week 14
Medical Home Team
Members
AOM - Pamela Gregg-Flax
Bio - Allen Cline
Health - Thang Bui
Reason for visit
•50-year old Hispanic male, well
nourished, well developed, AOx3
complains of R hip pain and
nonspecific back pain.
Subjective
• Patient reports motorcycle accident at age 14,
resulting in bilateral femur breaks.
• A total of 7 breaks between both legs.
• Surgical intervention included L acetabular-femur
fusion.
• Intervention resulted in surgical scar on L leg.
• Patient reports limited L knee mobility due to scar tissue.
Subjective (cont’d)
• Patient also complains of back spasms,
• Bilaterally with pain on R>L.
• Pain is greater in lumbar region, but radiates up to cervical spine.
• Due to predominantly L sided pain, patient compensates stride and is
experiencing R hip pain.
• Pain is exacerbated by prolonged standing and walking.
• Pain is alleviated by physical therapy and acupuncture.
• Pain on leg is constant and is localized to area around scar.
Medical History
• PMH: Type 2 Diabetes, Hypertension
• PSH: Post MVA surgery to repair femur breaks and
fuse L acetabulum and femur head in 1980.
• FMH: Family history of diabetes and hypertension
Social History
• ETOH: 5-7 drinks/week
• TOB: cigarette use, amount not reported
• No recreational drug use reported.
• Patient is unmarried and lives alone
Medications and Supplements
• Centrum Silver QD dosage not reported;
• Losartan dosage and timing not disclosed;
• Metformin dosage and timing not disclosed;
• Glucosamine/Chondroitin QD dosage not reported.
• NKDA
Additional Information
• Patient does not require mobility aids. He has
previously used chiropractic, but is not currently
under care. Patient does not take pain medication.
• Patient is insured by Blue Cross Blue Shield of Texas,
which covers acupuncture treatments.
Objective
• Vitals
• BP: L Seated 128/68; P: 74; R: 16
• TCM
• Pulse:
• L: deep, slippery, slightly weak in HT, deep KD Yin;
• R: slippery, slightly empty, LU/SP weak, KD Yang deep;
• Tongue:
• swollen quivering body, slight depression in Lower Jiao, red spots on tip with teeth
marks, tongue bifurcated, thick yellow coat, and slight sublingual venous congestion.
Physical Exam and ROS
• Examination of L leg shows pale keloid scar originating
L lumbar and extending to L lateral malleolus,
following course along L lateral leg.
• ROM exams were not performed due to patent
sensitivity.
• All other systems unremarkable.
Assessment
• 50-year old male with generalized bilateral back
pain, R hip pain, L leg pain with LROM in L knee.
• TCM Differentiation: Qi and Blood stasis in
Shaoyang Sinew channels.
Plan
•Acupuncture treatment:
• 1 – Patient in R Lateral Recumbent position
• L scar treatment using “Surround Dragon” with 13 needles,
medial knee “Surround Dragon” with 3 needles, (L)GB44,
ST45, SP1, DU4, UB20, 23, GB20.
• 2 – Patient in Prone position
• (R) “Surround Dragon” around GB30 with 5 needles, (R)
GB32, 34, 40, (R) K3.
Plan (cont’d)
• Herbs not indicated this visit.
• Patient was instructed to “keep moving” and perform light exercise to
tolerance, lower sodium intake, sleep on R side when possible, limit
TOB and ETOH consumption, avoid prolonged sitting, and to take hot
baths to help relieve pain.
• Patient was advised to continue weekly acupuncture treatments,
Additional Information
• CPT Codes: 98710, 98711
• ICD-9 Codes: 719.45, 724.5
• ICD-10 Codes: M25.551, M54.5